I started OBGYN last week at Wishard hospital. Each day rotates between clinic, surgery and labor & delivery. In clinic we do OB visits, annual exams with Pap smears and things like LEEP procedures (look it up but be prepared, your cervix will hurt just thinking about it…). OR days include hysterectomies, ovarian cyst removals, endometrial tissue biopsies and a lot more. L&D is well, the BEST THING EVER. Babies everywhere. And every kind of bodily fluid imagineable everywhere. I’ve been amazed at the positive attitudes and commitment to teaching shown by the residents. They make time to allow us, as students, to practice procedures or help with suturing, even in times of high stress, which leads me to the “reality” of OBGYN when things are good, they are great. And when they are bad, they are unthinkable.
Each of us students get to spend one week on nights helping with deliveries and triaging patients with bleeding during pregnancy, preterm contractions, etc. A few days ago I was on nights and we were busy triaging patients to see which should be admitted for delivery and which could go home until their true labor started. We were called urgently into one of the rooms for a patient who had developed copious vaginal bleeding a few hours before. It’s not uncommon to have spotting during pregnancy for a number of reasons, and some women experience bleeding when their “water breaks” during labor. This was different. She was brought up to our floor with fetal heart rate in the 60s (normal is 110-160 for a neonate). She was between 32 and 34 weeks (term is 39 weeks) and had had no prenatal care. While the residents were frantically searching for a heartbeat with ultrasound, I happened to glance at the urine sample she had just given. This wasn’t the expected “tea-colored” urine common with vaginal bleeding. There was no urine in the cup. It was straight-up blood. When the fetal heart tones couldn’t be located we ran to the OR. While on the way to the OR she admitted to cocaine use the night before.
Since starting surgery block I’ve learned that there is a TON of tedious but important prep that happens in the OR before each surgery, consisting of cleaning the room, setting up all the possible equipment sterily, cleaning the patient, putting them to sleep, scrubbing in, prepping the sterile field around the patient and taking multiple time outs to ensure proper patient and proper procedure. This all usually takes 20-30 mins.
This OR visit was complete chaos. Anesthesiologists, OBGYNs, NICU docs and nurses for all of them were scrambling at once for supplies and gowns. I grabbed my mask and hair cap and tried to stand out of the way which was proving to be fruitless. I was quickly called over by an anesthesiologist attending to hold the oxygen mask while they put in IVs and got drugs ready. I also held pressure on the esophagus while they intubated to ensure proper placement in the trachea and prevent reflux and aspiration of stomach contents since our patient hadn’t had the normal eight hours of fasting before surgery. I tried to stand in as little space as possible while residents passed tubing, clips and EKG leads around me.
Once our patient was prepped the OB residents started cutting. I watched them cut the skin, muscles, fascia and finally the uterus, pulling out a pale but large enough baby girl. What felt like 10 mins as I held my breath actually took only a few seconds. The residents tried to stop the bleeding as they examined the uterus that had just held an abrupted placenta. While they threw bloody rags and placenta pieces around me the chief resident took time to tell me to scrub in. I rushed to get cleaned and gowned and the attending and residents showed me the 75% abruption. The uterus was gray and bruised, quite a stark contrast from the normally red and glistening gravid uterus. There was a fibroid and also old scarring, suggesting past pelvic inflammatory disease. They had me retract the skin while they sewed the uterus and fascia back together while the NICU staff ran to get blood and frantically tried to resuscitate the baby who initially had a heart rate in the 20s but wasn’t breathing.
The chief resident took time to help me sew up the skin, even though I’m painfully slow, so much so that the muscle relaxants were wearing off and abdominal wall was moving with each of her breaths as I tried to finish sewing. As we finished cleaning her up, the NICU staff pronounced the time of death for the baby. They wrapped her up in a blanket and hat just like all the newborns as we took her mom to the PACU. The amazing nurses took the prettiest baby I have ever seen, dressed her in a white dress and bonnet and took pictures to make a little album for her family of pics of her little hands and feet and angelic face. The mother got to hold her to say goodbye and they kept her safe until the father of the baby was able to come to the hospital as well.
The mood was somber for the rest of the night. The residents made sure I was ok and answered all my questions as they replayed the events outloud, trying to find where they might have messed up by delaying the diagnosis or the decision to go to surgery or the delivery, knowing they full well did exactly as they should have. They explained to me that lots of patients use cocaine and various other drugs during pregnancy that only rarely have devastating outcomes. But this patient just happened to have a perfect storm of past medical history that predisposed her to disaster if any other insults were added. Abruption is a gravely feared event with a 35% fetal mortality.
But we went on our way appropriately tending to other patients. Later that night I helped with my first vaginal delivery. It was incredible. The baby quickly adjusted to life on land, even smiling and looking around with huge, beautiful, brown eyes. I could have cried, both from happiness and also from cringing at the second degree laceration the mom incurred as she ripped through her vagina and perineal body. If the anticipated pain of labor hadn’t convinced me to want an epidural if I should be so lucky to have a kid someday, watching the laceration did. I can’t imagine being able to feel a baby’s noggin rip a giant hole down there. But regardless, it was a much-needed moment of sheer joy at this young family’s firstborn’s birth day.
I’ve watched patients die before, from coding due to multiple comorbidities combined with age, from trauma and even from brainstem herniation. All of these events sucked. A lot. But nothing gave me seemingly never-ending chills like watching a perfectly viable pregnancy end in unnecessary death. Med school life lesson #561: learn to accept death of all kinds while still striving to prevent it and prolong meaningful life. Do all this all the while stop yourself from being judgmental and angry at the people who may be responsible. Part of me was fraught with rage at the mother but for some reason my chills kept me cooled down. My chief resident was able to explain what I and they were feeling but that I couldn’t describe. 1) There are so many people who would give everything to take care of a perfect baby, including this little girl. 2) It’s absolutely unimaginable to lose a child. Period. And living with that for the rest of your life? Unthinkable.
And so in the end we rightfully sympathize with mother, not even remotely condoning or excusing her actions but rather ignoring that fact and validating her pain at the death of part of her.
Just when you think med school is getting easier, it doesn’t.